Abstract Background To explore the feasibility, safety, and indications of the modified Appleby operation for carcinoma of the body and tail of the pancreas and to identify prognostic factors. ...Material and methods Data from a total of 15 patients receiving the modified Appleby operation in our department were retrospectively analyzed. Correlation analyses and univariate and multivariate analyses of the survival time were performed to identify prognostic factors. Results The operations were successful in all 15 patients. The median survival time was 19 mo except in one case, where the patient died; and the 1- and 3-y survival rates were 86.7% (13/15) and 6.7% (1/15), respectively. A positive correlation was found between age and survival time ( P = 0.037, Pearson correlation = 0.541). In addition, univariate analysis, age, operative time, and perineural invasion were correlated with survival time ( P = 0.029, 0.035, and 0.049, respectively). Finally, multivariate analysis revealed that only age ≥60 y was correlated with survival (Hazard ratio = 0.263, P = 0.044). Conclusions The improved Appleby operation was feasible and safe when performed in experienced centers by experienced surgeons and can improve the patients' survival time and quality of life. Statistical analysis suggests that elderly patients may have a better prognosis than younger patients to some extent.
Abstract Background Higher body mass index (BMI) has been associated with postoperative complications in total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, the association of ...incremental increases of BMI and its effects on postoperative complications has not been well studied. We hypothesize that there is a BMI cutoff at which there is a significant increase of the risk of postoperative complications. Methods We studied the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2013. The final cohort included 77,785 primary TKA and 49,475 primary THA subjects, respectively. Patients were separated into 7 groups based on BMI (18.5-24.9 kg/m2 , 25.0-29.9 kg/m2 , 30.0-34.9 kg/m2 , 35.0-39.9 kg/m2 , 40.0-44.9 kg/m2 , 45.0-49.9 kg/m2 , and >50.0 kg/m2 ). We analyzed data on five 30-day composite complication variables, including any complication, major complication, wound infection, systemic infection, and cardiac and/or pulmonary complication. Results The odds ratio for 4 (any complication, major complication, wound infection, and systemic infection) of 5 composite complications started to increase exponentially once BMI reached 45.0 kg/m2 or higher in TKA. Similarly, the odds ratio in 3 (any complication, systemic infection, and wound infection) of 5 composite complications showed similar trends in THA patients. These findings were further confirmed with propensity score matching and entropy balancing. Conclusions Our study suggested that there was a positive correlation between BMI and incidences of 30-day postoperative complications in both TKA and THA. The odds of complications increased dramatically once BMI reached 45.0 kg/m2.
Monthly incidence of elbow ulnar collateral ligament (UCL) injuries and surgeries is relatively unknown. Defining seasonal peaks of UCL injuries and surgeries may identify opportunities for ...injury-prevention strategies. The purpose of this study is to analyze seasonal and monthly variations in UCL injuries and surgeries across the United States with emphasis on the timing of baseball season.
The Truven Health MarketScan database (2013-2015) was queried for patients younger than 40 years with a diagnosis code of elbow UCL sprain and a procedural code for UCL repair or reconstruction. Differences in patient characteristics were evaluated using chi-square and Mann-Whitney U-tests. Negative binomial regression models were calculated for UCL injuries and surgeries to assess monthly trends.
UCL injuries were sustained by 13,894 patients, with 1404 (10.1%) patients having undergone surgery. The median age at first diagnosis was 17 years, and the median age of patients requiring surgery decreased from 20 to 18 years from 2013 to 2015 (P = .75). Most UCL injuries (n = 3785) and surgeries (n = 438) occurred during the spring season (March 21-June 20), and spring injuries were most likely to result in surgical management (11.6%). During the baseball season (March to September), the number of UCL injuries peaked in April/May, then declined, except for a second peak in September/October (incidence rate ratio 0.97; confidence interval 0.95, 0.99; P = .01). The number of UCL surgeries steadily increased from March (n = 116) to June (n = 152), followed by a gradual decline (incidence rate ratio 1.00; confidence interval 0.96, 1.04; P = .99).
Athletes frequently experienced UCL injuries and surgeries in the early months (April-June) of the baseball season. More emphasis should be paid to rehabilitative strategies at the beginning of a baseball season to help mitigate injury risk.
Abstract The concept of staging during the same hospitalization for bilateral total knee arthroplasty (BTKA) has emerged as a practice to minimize perioperative risks, although with few data ...providing an evidence base. A total of 41,664 BTKA patients from Nationwide Inpatient Sample data between 1998 and 2010 were identified, and categorized into three groups, same day, staging 1–3 days, and staging 4–7 days BTKA. Staging BTKA 1–3 days apart was associated with increased rates for complications compared to same day BTKA, while staging 4–7 days BTKA was associated with similar complication profiles compared to same day BTKA. Our study suggests that same day BTKA for selective patient population is preferable, and staging BTKA either 1–3 days or 4–7 days apart should be discouraged.
Abstract Health care reform is directing clinical practice towards improving outcomes and minimizing complications. Preoperative identification of high-risk patients and modifiable risk factors ...present opportunity for clinical research. A total of 49,475 total hip arthroplasty patients were identified from National Surgical Quality Improvement Program between 2006 and 2013. We compared morbidly obese patients (BMI ≥ 40 kg/m2 ) and non-morbidly obese patients (BMI 18.5–40 kg/m2 ). We also compared patients with hypoalbuminemia (serum albumin < 3.5 g/dL) against those with normal albumin. Our study demonstrates that hypoalbuminemia is a significant risk factor for mortality and major morbidity among total hip arthroplasty patients, while morbid obesity was only associated with an increased risk of superficial surgical site infection. Impressively, hypoalbuminemia patients carried a 5.94-fold risk of 30-day mortality.
Hip fracture is one of the most common orthopedic conditions associated with significant morbidity and mortality. Patients with hip fracture are usually older, with significant comorbidities. Delayed ...surgical treatment beyond 48 hours after admission is associated with significantly higher mortality. Hereby clinicians are presented with the challenge to optimize the complex hip fracture within a short time period. This article reviews the evidence regarding preoperative, intraoperative, and postoperative considerations, and provides insights into the best strategies with which to optimize the patient's condition and improve perioperative outcomes.
Abstract Study objective The study objective is to examine the analgesic effect of 3 doses of dexamethasone in combination with low concentration local anesthetics to determine the lowest effective ...dose of dexamethasone for use as an adjuvant in supraclavicular brachial plexus nerve block. Design The design is a prospective randomized double-blinded clinical study. Setting The setting is an academic medical center. Patients The patients are 89 adult patients scheduled for shoulder arthroscopy. Interventions All patients were randomly assigned into 1 of 4 treatment groups: (i) bupivacaine, 0.25% 30 mL; (ii) bupivacaine, 0.25% 30 mL with 1-mg preservative-free dexamethasone; (iii) bupivacaine, 0.25% 30 mL with 2-mg preservative-free dexamethasone; and (iv) bupivacaine, 0.25% 30 mL with 4-mg preservative-free dexamethasone. All patients received ultrasound-guided supraclavicular brachial plexus nerve blocks and general anesthesia. Measurements The measurements are the duration of analgesia and motor block. Main results The median analgesia duration of supraclavicular brachial plexus nerve block with 0.25% bupivacaine was 12.1 hours; and 1-, 2-, or 4-mg dexamethasone significantly prolonged the analgesia duration to 22.3, 23.3, and 21.2 hours, respectively ( P = .0105). Dexamethasone also significantly extended the duration of motor nerve block in a similar trend ( P = .0247). Conclusion Low-dose dexamethasone (1-2 mg) prolongs analgesia duration and motor blockade to the similar extent as 4-mg dexamethasone when added to 0.25% bupivacaine for supraclavicular brachial plexus nerve block.
Introduction:
Hip fractures in the elderly individuals are associated with significant morbidity and mortality, and outcomes are directly related to prompt surgical intervention with either total hip ...arthroplasty (THA) or hemiarthroplasty. Minority hip fracture patients have increased delays to surgical intervention and poorer functional outcomes. This study explored racial biases in the surgical treatment decision between THA and hemiarthroplasty for displaced femoral neck fractures as well as racial disparities in postoperative complications, readmission rates, and 30-day mortality.
Methods:
We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2014. Patients were identified using diagnosis code for transcervical femoral neck fractures and Current Procedural Terminology codes for THA or hemiarthroplasty. A multivariable regression analysis was conducted including race, demographic information, and medical comorbidities.
Results:
Of 11 408 patients, race was recorded in 8538 individuals. Most patients were white (88.3%), followed by Hispanic (4.7%), African American (4.1%), and Asian/Native Hawaiian/Pacific Islander/American Indian/Alaska Native (2.9%). No differences were observed in the likelihood of receiving a THA versus hemiarthroplasty among racial groups. Only younger age and steroid use were independent risk factors for receiving a THA. Race was significantly associated with postoperative mortality (P = .014) and major postoperative complications for the Asian cohort (P = .013).
Discussion:
The NSQIP data do not support a racial bias in the selection of patients for THA versus hemiarthroplasty. However, this study found racial disparities in postoperative mortality and complications. The reasons underlying the differences in postoperative outcomes are uncertain but may be the result of specific challenges to accessing care.
Conclusion:
There was no racial bias in the treatment of femoral neck fractures. However, there were racial disparities in postoperative mortality and complication rates. Further research is warranted to elucidate the true causes of these observed disparities.
As procedure rates and expenditures for total hip arthroplasty (THA) rise, hospitals are developing models to predict discharge location, a major determinant of total cost. The predictive value of ...existing illness rating systems such as the American Society for Anesthesiologists (ASA) Physical Classification System, Severity of Illness (SOI) scoring system, or Mallampati (MP) rating scale on discharge location remains unclear. This study explored the predictive role of ASA, SOI, and MP scores on discharge location, lengths of stay, and total costs for THA patients.
A retrospective analysis of patients undergoing elective primary or revision THA was conducted at a single institution. Multivariable regressions were utilized to assess the significant predictive factors for lengths of stay, total costs, and discharge to skilled nursing facilities (SNFs), rehabilitation centers, and home. Controls included demographic factors, insurance coverage, and the type of procedure.
ASA scores ≥3 are the only significant predictors of discharge to SNFs (odds ratio OR = 1.69, confidence interval CI = 1.04-2.74) and home (OR = 0.57, CI = 0.34-0.98). Medicaid coverage (OR = 2.61, CI = 1.37-4.96) and African-American race (OR = 2.60, CI = 1.59-4.25) were additional significant predictors of discharge to SNF. SOI scores are the only significant predictors of length of stay (β = 1.36 days, CI = 0.53-2.19) and total cost for an episode (β = $6,234, CI = $3577-$8891). MP scores possess limited predictive power over lengths of stay only.
These findings suggest that although ASA classifications predict discharge location and SOI scores predict length of stay and total costs, other factors beyond illness rating systems remain stronger predictors of discharge for THA patients.
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